When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement?
Reference Range
lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]
Determine apical pulse rate and rhythm.
Observe color and amount of urine.
Assess strength of deep tendon reflexes.
Compare muscle strength bilaterally
The Correct Answer is A
A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","G","H"]
Explanation
A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.
C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.
Correct Answer is ["A","B","C","H"]
Explanation
A. A case manager can coordinate the overall care plan, ensuring the client receives appropriate services and support during recovery and discharge planning.
B. An occupational therapist can help the client regain the ability to perform activities of daily living (ADLs) and improve fine motor skills affected by the stroke.
C. A speech therapist can assist the client with speech and language difficulties, as well as swallowing issues that may have resulted from the stroke.
D. A respiratory therapist is typically involved if there are respiratory issues, which are not indicated in this case.
E. A chief nursing officer provides leadership and oversight roles, and not direct patient care.
F. A medical assistant is typically involved in basic clinical tasks but not in specialized stroke recovery.
G. A pharmacy technician fills prescriptions but doesn’t directly participate in client rehabilitation.
H. A physical therapist can help the client improve strength, balance, and mobility, which are often impaired after a
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